Selected as a top priority area in the Institute of Medicine's report Transforming Health Care Quality, healthcare associated infections (HAIs) contribute to unnecessary morbidity and mortality in hospitalized patients. The Center for Medicare & Medicaid Services no longer reimburses for costs associated with certain HAIs. National organizations have recommended the public reporting of HAI rates by hospitals. For valid and fair HAI comparisons, risk adjustment methods may be required. The organism Clostridium difficile, which causes diarrhea, has become a common microbial threat for patients, probably due to a recently emerged epidemic strain of C. difficile. Antibiotic and gastric acid suppressant therapy and infection control polices are regarded as the main risk factors for C. difficile infection (CDI). Assessing risk factors at the hospital-level enables hospitals to identify their institutional-specific risks. This career development award is being sought by an infectious diseases pharmacist who is currently a tenure-track Assistant Professor. The K08 will provide protected time and mentored research experiences to develop the candidate in the area of health services research, patient safety, and infectious disease epidemiology. She will complete a Ph.D. degree in VCU's Health Administration program with in-depth training in relevant areas such as mixed-method research methodologies, advanced modeling techniques for risk adjustment, and healthcare organization and research. Under the guidance of a highly qualified team of mentors, she is committed to becoming an established, independent researcher who contributes to the evolving field of translating effective strategies for prevention of HAIs into practice and to provide remedies to the challenge of decreasing the occurrence of these infections. Using CDI as a model organism, the research phase will develop strategies to evaluate hospital-level factors associated with increased HAIs among a consortium of large, safety net hospitals. Valid methods for fair risk- adjustment will permit interhospital comparisons of CDI rates, as well as other HAIs. Further, acquiring deeper insights into why hospitals adopt or do not adopt effective CDI prevention practices is valuable to the understanding of the facilitators and barriers to implementation of effective prevention measures. Specific aims include: (1) To evaluate the extent to which hospital-level antibiotic and gastric acid suppressant usage patterns, infection prevention and control, and pharmacy policies predict on CDI occurrence; (2) To develop and compare various approaches to risk adjustment to identify hospitals with higher (or lower) than expected CDI rates; (3) To identify facilitators and barriers to implementation of best practices for CDI prevention. The research proposed will use a state-of-the-art mixed-method approach including hierarchical models incorporating both patient- and hospital-level data, development of a standardized comparison of CDI rates across hospitals, and a strategy to aid hospitals to identifying priority areas for CDI infection prevention efforts. The methods developed for CDI can then be applied to other HAIs.